By Jill Lawrence

Reuters

Republicans are having a bad month, but they should cheer up. Sure, conservative lawmakers have flamed out in dozens of attempts to defund, delay, repeal and pick off pieces of the Affordable Care Act, and the GOP has taken the brunt of voter outrage over the shutdown precipitated by that crusade. Yet with a big assist from its governors, the party has already done damage to Obamacare in numerous, possibly profound ways.

Let's start with the disastrous launch of the behemoth federal insurance exchange run by the Health and Human Services Department. Yes, Republicans managed to divert attention from that to their own comedy of errors on Capitol Hill. But don't forget why the federal exchange, healthcare.gov, is so gigantic. It's because just 16 states and the District of Columbia created or plan to create their own marketplaces. By contrast, almost all of the nation's 30 Republican governors took a pass on setting up exchanges for their own states, punting that task to the feds. That along with other tactics and decisions amounts to what you might call the GOP Effect—damage that's indirect, often uncoordinated, and possibly at times unintentional, but potent all the same.

For instance, some of the initial problems on the federal exchange were due to heavy traffic. It would not have been as much of a bottleneck had more governors created individual state exchanges. More serious and continuing problems are due to misjudgments and shortcomings embedded in the federal website itself, and the worst may be yet to come.

The 16 states that built their own sites have used a variety of contractors and many of their marketplaces have launched more smoothly than the federal healthcare.gov. The bottom line is that the pressure on the federal exchange would have been far less and its design flaws would have affected many fewer people had, say, 20 more states set up their own exchanges using a variety of contractors and approaches.

There's also a toll that comes from having to set up systems to run or help run three dozen exchanges. That took time that might have been spent preparing for a smoother opening. "The federal exchange has to interact with health plans that are submitting bids in 36 states, and also has to work out data agreements with how to handle information flow with 36 different Medicaid agencies, and they've had to work out insurance oversight with 36 state insurance departments," says Alan Weil, executive director of the National Academy for State Health Policy. "It's a huge workload that competes for resources with building the exchange functionality."

Some of the states that left exchanges to the federal government have not put any or many resources toward signing people up. Since the law depends on high enrollments to broaden the risk pool and keep coverage costs relatively low, these governors may have helped create conditions ripe for higher rates and consumer backlash against the law.

More backlash could arise when unfair aspects of the law become fully apparent. Democrats wrote into the bill that people below a certain income would qualify for a Medicaid expansion paid 100 percent by the federal government for three years. But when conservatives on the Supreme Court turned that into an option rather than a requirement, most Republican governors either chose not to do it or couldn't get their legislatures to agree to the expansion. The upshot is that low-income working people will get subsidies on the exchanges, but workers with even lower incomes will be cut out of subsidies because they qualify for Medicaid coverage their state has chosen not to offer. There's going to be anger and criticism about this—the only question is whether it will be directed at governors or the law itself.

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The January 2010 special Senate election in Massachusetts was another pivotal moment for the Affordable Care Act. Republican Scott Brown won in part by promising to stop Obamacare. He did not succeed at that. But his victory did end the Democrats' filibuster-proof 60-vote majority and the possibility of any changes or improvements in the bill. The Democratic-controlled House had to simply accept the Senate bill if anything was going to pass at all.

Among the House ideas that fell by the wayside: a simpler way for larger businesses to comply with the mandate to provide health insurance. "Representatives in the House had what was probably a better idea: to make employers devote a certain percentage of their payroll to health insurance, instead of doing it by the number of full-time workers," bioethicist and former White House adviser Ezekiel Emanuel wrote in The New York Times when what he called the "overly complicated" employer mandate was postponed for a year.

The upshot has been a beleaguered business community up in arms about the burdens of the law, a one-year delay in the employer mandate, and endless fodder for anecdotes about jobs cut, expansions nixed, and health benefits dropped. That's just one example of how implacable GOP hostility toward Obamacare, and ironclad resistance to making it work better, is producing political dividends for Republicans. And there's more where that came from, if they can manage to shift the focus from their own dysfunction to the health care launch from hell.